THE VAGINA EPILOGUE

01-November-2017

RAJGOPAL NIDAMBOOR

First a little story. A petite girl saw a bleak, desolate future in store. Not because she was born in a rural area, or family that could hardly meet its basic needs, but because she was ‘bereft’ of her ‘V’ aspect. A new revolutionary restorative surgical procedure changed her life. She is now happily married and savouring conjugal bliss with a man who’d earlier lost his wife. In her words, “What more could I’ve asked for from god? I’ve a well-kept house, a ‘prêt-à-porter’ caring husband and child, good food to eat and decent clothes to wear. Something that was, just the other day, not only a far-flung, but almost impossible dream.”

An Indian gynaecologist fell in love with a fellow doctor abroad, who knew that the lady he adored had a major missing element in her anatomy. The duo happened to read about the innovative surgical option in a medical journal. They boarded a flight to Mumbai, went straight to the doctor and discussed the prospect. The lady underwent the procedure successfully, got married to her love, a few weeks later, and embarked on their honeymoon. It did not take long, thereafter, for them to find a surrogate mother who was subsequently delivered of their baby, their little bundle of happiness — something they had not visualised as a remote possibility.

It is a subject that is as rigorously masked as the top, surreptitious vault in the intelligence service. Yet, the fact is depressing. It is reported that the ‘biological absence’ of the vagina, the anatomical ‘pink’ element of womanhood, occurs in one in 4,500. For the girl having the anomaly, it is nothing short of a volcanic upsurge in the mind — an inescapable niggling question of one’s sexuality, natural feelings, and identity. For parents, the gauche prospect rings the ominous bell of misfortune, disaster and social isolation — at the spur, or thought, of someone outside of the family getting to know about it. It is also apparent that the whole spectre of gloom steals the possibility of a ‘distant’ marriage, or relationship, from the word ‘go’ — even when one falls in love, or elopes. Because, the looming shadow of ‘detection’ signals the beginning of the end of the fragile thread of hoping against hope for acceptance, not just conjugal happiness.

More than anything else, the eerie, ‘empty’ syndrome not only impacts one’s emotional and psychological bearings, it also leads to ostracisation within the family’s immediate or outside circle, with the question of the girl being labelled as ‘odd,’ or even bad omen. For some individuals, it ushers, no less, a sense of surging foreboding, also calamity, of being ‘stuck’ with something strange — a dismal ticket with a veiled, or palpable, suicidal presage or augury.

The development from the Müllerian duct is one of the most celebrated, also ill-understood, topics in gynaecology — although it forms the fundamental underpinning of every woman’s reproductive anatomy. The Müllerian ducts — named after Johannes Peter Müller, a German physiologist, who first described them — originate in the embryo. They culminate in what is called as the Müllerian eminence in the primitive urogenital sinus [cavity]. They also form the fallopian tubes, uterus, and the upper portion of the vagina. The whole process is a marvel. Of how different segments of the Müllerian ducts develop into different structures — the fallopian tube as the thin supple peristaltic organ, the thick distensible and contractile uterus endowed with local immune function, the thick competent and distensible cervix and, of course, the extremely elastic vagina.

It is, indeed, nature’s amazing complexity that endows each part with diverse reproductive functions. The development and differentiation of the Müllerian ducts are not only important at the foetal stage, their progression in adult life explicates the pathogenesis of several gynaecological conditions, such as endometriosis — a disorder in which the tissue that normally grows inside the uterus extends outside of the uterus — and, ovarian neoplasm, or benign or malignant cancer.

To cut a long story short — the total absence of the Müllerian progression leads to aplasia, or defective development or congenital absence of the ‘V’ organ, while partial development, a common occurrence, leads to tubal and skewed uterine development, not to speak of the complete absence of the upper three-fourth of the vagina. In most cases of absent vagina, the uterus is typically incomplete, or rudimentary. The ovaries are, however, normal, but they are placed on the lateral pelvic wall, along with the uterus. The overall inference: a dire, barren prospect of being unable to conceive, or give birth to a child. In medical phraseology, this is called the Mayer-Rokitansky-Küster-Hauser [MRKH] syndrome. Research suggests that it may connote a genetic basis, or contextuality.

Most girls presenting with the disorder may have normal secondary sexual development, such as the breasts. Yet, there may be associated congenital anomalies of the urinary tract — such as a horse-shoe shaped kidney with the failure of the organ to develop during embryonic growth. This may be present in 30-40 per cent of individuals having MRKH syndrome, while 10-15 per cent may show skeletal anomalies.

Is there a way or hope for girls with the rudimentary vagina to have a normal, happy conjugal life? There is, thanks to revolutionary research and techniques formulated by doctors in the past and most recently by Dr Pravin Mhatre, a Mumbai-based gynaecologist, who also pioneered the world’s first avant-garde ovarian transplant, over a decade ago, along with Dr Jyoti Mhatre — a husband-wife team — and, Dr Rakhi Sahu, The novel procedure has earned plaudits from both doctors and researchers alike, especially abroad. Their work is yet to receive adequate attention in the country of its origin — a paradox with our psyche and also the powers-that-be.

The Mhatre assay is a technological advance over several operative options available for the creation of ‘neovagina.’ It is practically free of complications and disadvantages of procedures in use, such as free skin graft, intestinal or sigmoid vaginoplasty, amnion graft, and pelvic peritoneum graft, not to speak of complications reported with varying patterns — viz., stenosis [narrowing], poor lubrication, scarring, dyspareunia [painful coitus] and the need for laparotomy, a surgical procedure, to overcome such negative barriers. Yet another downside of the ‘older’ procedures is the possibility of squamous cell carcinoma [cancer] from free skin graft and adenocarcinoma, a type of cancer that forms in the mucous-secreting glands of the body. This is not all. The amnion graft, or membrane transplantation, to ‘sculpt’ the neovagina, or vaginal ‘reconstruction,’ is suggested to transmit hepatitis, or human immunodeficiency virus [HIV], although the use of freeze-dried amnion has been evidenced to prevent such transmission. Interestingly, the creation of neovagina by way of endoscopic-assistance [Vecchietti technique], in the recent past, has received much attention, yet the fact is the procedure is complex, time-consuming and laden with potential complications.

The use of peritoneum — the serous membrane that forms the lining of the abdominal cavity — in vaginoplasty, a reconstructive plastic surgery and cosmetic procedure for the vaginal canal, was first popularised by Davydov, a Russian gynaecologist. He reported a series of 28 patients with good results in eight months. His conventional surgery is currently being replaced by laparoscopy, which was inevitable and also predictable. The laparoscopic modification has resulted in a shorter operating time and reduced post-operative morbidity. Yet, it does not have the advantages of the Mhatre technique. This is not all. While several reconstructive surgical procedures have been described for vaginal agenesis, or failure of the vagina to develop, almost all of them are surgically challenging, multi-staged, time-consuming and have the likelihood of causing permanent scars on the abdomen, or the skin retrieval [graft] sites used for the reconstructive procedure.

The new simple and effective technique using laparoscopic peritoneal ‘pull-through’ for the creation of the neovagina is what the Mhatre duo and Sahu have pioneered and used with good, replicable results. Their work also validates the procedure’s success in thirty-six patients, aged between 16 and 27, with congenital absence of the vagina [MRKH syndrome]. The trio used three different techniques for peritoneal vaginoplasty. They followed up on their patients for over a period of 1-7 years. The results are tangible — the peritoneal lining changes not only resembles normal vagina, but also provides for “excellent normal vaginal function.” More importantly, as the ovary became accessible via vagina, three patients underwent ovum retrieval and pregnancy, while using surrogate mothers, giving the whole process a life-changing tag — a fertility-enhancing procedure.

Interestingly, three of the patients were from the medical fraternity with two of them [read example two, relating to one of them, at the beginning of this piece] being gynaecologists. Apart from routine pre-operative work-up, a diagnostic laparoscopy was performed to determine mobilisation and feasibility of creating anterior and posterior flaps for the peritoneal ‘pull-through’ to see the size and position of the utricles on lateral pelvic walls and also establishing the possibility of uterine implantation in the neovagina procedure.

During follow-up, as the Mhatres explain, the neovaginal space is dilated gradually to maintain the desired length till sexual activity is resumed. Dilatation using a glass dilator increases the length and diameter of the neovagina and also changes the axis ideal for intercourse. The neovagina, as the Mhatres put it, is in the precise anatomical axis. They also add that the pelvic peritoneum lining the neovagina is receptive to oestrogen, the female hormone.

The design of their study, as the Mhatres explain, was retrospective. 90 per cent of patients required supervised glass dilatation in the first post-surgical week. 100 per cent of women required vaginal lubrication for the first three months. The need for lubrication declined drastically after 6-9 months in the married group of patients [66.5 per cent]. While 50 per cent of patients complained of pain and discomfort in the first few weeks, pain-free intercourse followed after 3-6 months. When the patients were asked their view on the optimal timing of surgery, 72 per cent favoured that the “operation should be performed earlier.” They contended that whatever delay that elapsed for seeking professional medical help was primarily because of the social disgrace attached to the absent vagina — aside from the general belief of correlation with the ‘transgender’ label, or some curse, or bad omen.

The results were impressive: the average operative time was 1-1.5 hours and the average hospital stay was three days, except in two cases, which required five days. There were no major complications, except for one patient who had a rectal problem. This was managed by suturing; the recovery was uneventful. On follow-up, the patients had adequate, comfortable vaginal length of about 7-8 cm, admitting full-size speculum. Sexual satisfaction on follow-up was also good. Of the 36 patients, nine were married and 15 patients got married after vaginoplasty. They reported of no sexual difficulty with themselves, or their partner. More than 90 per cent of patients were positively happy after having a successful vaginoplasty, with no obvious signs of surgery. The successful vaginoplasty [neovagina] procedure has not only reassured patients, with the incomplete ‘V,’ but it has also changed their and their families’ outlook and acceptance dramatically too.

If this isn’t a life-changing, medical perestroika for hapless girls, and women, with ‘absent’ vagina, to shedding the dismal shadow of misery, or stigma, and embracing ‘born-again’ womanhood, what is?